Basic Information
| Provider Information | |||||||||
| NPI: | 1790295095 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WINN | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | WIILLIAM | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 SNOWFLAKE ST | ||||||||
| Address2: | |||||||||
| City: | AMERICAN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832111178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4359949993 | ||||||||
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| Practice Location | |||||||||
| Address1: | 330 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ABERDEEN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083974126 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2017 | ||||||||
| LastUpdateDate: | 10/02/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA-1535 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.